I was recently asked about the appropriateness of coding both CPT codes 29875 (arthroscopic plica removal) and 29881 (arthroscopic meniscectomy) for the same episode of care. This “In the kNOW” installment will provide the answer and examine the rationale behind it.
CPT code 29875 is assigned for a limited synovectomy. This procedure is often referred to as a plica resection or shelf resection, and within CPT, it carries a designation of being a “separate procedure”. This “separate procedure” designation is often where the confusion lies. In general, when a procedure is designated as a “separate procedure” it means it is considered to be fundamental component of a larger or more total procedure and is therefore, not to be coded additionally. However, as every coder knows, there are exceptions to every guideline provided, and the “separate procedure” is not exempt because, in circumstances where the “separate procedure” is clearly distinct from other procedures, it may be reported with modifier 59. In order for the exception to apply, the “separate procedure” must meet one of the following conditions:
Armed with this information, let’s now look at the coding question posed above. Our main procedure will be the arthroscopic meniscectomy as it is the more extensive procedure performed. In order to code the plica resection, it would have to meet one of the exceptions listed above, which normally it does not. These plicectomy procedures are usually performed through the scope insertion, at the same time as the more extensive procedure, and don’t represent a different lesion/injury. So this becomes the first clue that we shouldn’t code both of these procedures at the same time.
If we dig even deeper and find a copy of the procedure-to-procedure edits from the Centers for Medicare and Medicaid Services (CMS), we can identify that 29881 is the column 1 procedure with 29875 the column 2 procedure and an edit rationale that states 29881 is considered to be the more extensive procedure. We do find that we could bypass the edit with the use of an appropriate modifier, but again, keep in mind, that we would need to meet one of the exceptions that we mentioned above, which we don’t. However, if the plica resection was done in the left knee and the meniscectomy was done in the right knee, a modifier would be appropriate to indicate that both procedures should be paid in this instance since they meet the exception of different body site.
Further investigation takes us to the National Correct Coding Initiative (NCCI) edit manual. In Chapter 4 which addresses the musculoskeletal codes in the range of 20000-29999, we go to Section E-Arthroscopy, and then to #8. Here we are told that 29875 is not to be coded when any other procedure is also performed via arthroscopy in the same knee.
Our final confirmation is addressed in the CPT Assistant from January 2016 on page 11. That document reiterates the information related to “separate procedures” and states that 29875 is not to be coded with 29881.
It is clear from four different sources that coding of both 29875 and 29881 is not normally going to be reportable. Should a coder have a situation where one of the exceptions mentioned applies, use of an appropriate modifier will bypass the edit and trigger reimbursement.
Now you are in the kNOW!!
CPT code 29875 is assigned for a limited synovectomy. This procedure is often referred to as a plica resection or shelf resection, and within CPT, it carries a designation of being a “separate procedure”. This “separate procedure” designation is often where the confusion lies. In general, when a procedure is designated as a “separate procedure” it means it is considered to be fundamental component of a larger or more total procedure and is therefore, not to be coded additionally. However, as every coder knows, there are exceptions to every guideline provided, and the “separate procedure” is not exempt because, in circumstances where the “separate procedure” is clearly distinct from other procedures, it may be reported with modifier 59. In order for the exception to apply, the “separate procedure” must meet one of the following conditions:
- It represents a different session
- It was a different procedure/surgery
- It represents a different site or body system
- It required a separate surgical approach
- It was a different lesion
- It was a separate injury
Armed with this information, let’s now look at the coding question posed above. Our main procedure will be the arthroscopic meniscectomy as it is the more extensive procedure performed. In order to code the plica resection, it would have to meet one of the exceptions listed above, which normally it does not. These plicectomy procedures are usually performed through the scope insertion, at the same time as the more extensive procedure, and don’t represent a different lesion/injury. So this becomes the first clue that we shouldn’t code both of these procedures at the same time.
If we dig even deeper and find a copy of the procedure-to-procedure edits from the Centers for Medicare and Medicaid Services (CMS), we can identify that 29881 is the column 1 procedure with 29875 the column 2 procedure and an edit rationale that states 29881 is considered to be the more extensive procedure. We do find that we could bypass the edit with the use of an appropriate modifier, but again, keep in mind, that we would need to meet one of the exceptions that we mentioned above, which we don’t. However, if the plica resection was done in the left knee and the meniscectomy was done in the right knee, a modifier would be appropriate to indicate that both procedures should be paid in this instance since they meet the exception of different body site.
Further investigation takes us to the National Correct Coding Initiative (NCCI) edit manual. In Chapter 4 which addresses the musculoskeletal codes in the range of 20000-29999, we go to Section E-Arthroscopy, and then to #8. Here we are told that 29875 is not to be coded when any other procedure is also performed via arthroscopy in the same knee.
Our final confirmation is addressed in the CPT Assistant from January 2016 on page 11. That document reiterates the information related to “separate procedures” and states that 29875 is not to be coded with 29881.
It is clear from four different sources that coding of both 29875 and 29881 is not normally going to be reportable. Should a coder have a situation where one of the exceptions mentioned applies, use of an appropriate modifier will bypass the edit and trigger reimbursement.
Now you are in the kNOW!!
About the Author
Dianna Foley, RHIA, CHPS, CCS is
OHIMA's Coding Education Coordinator. Dianna has been an HIM
professional for 20 years. She progressed through the ranks of coder,
department supervisor, and department director, to her current role as a
coding consultant. She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.
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